Caregiver Application

Name

First NameLast Name
Full Address
Email
example@example.com
SSNSIN
Phone
Position you are applying for
Work Permit
Position you are applying for: Do you have a First Aid/CPR certificate? [If YES, please attach copy of certificate to application] Certification Registration #
Certification Registration
Expiry Date MMYYYY

MonthDayYear
Date
AVAILABILITY
Availability

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Desired Hourly Wage Amount?
How many hours can you work weekly?

4-1616-2626-40
Can you work nights?

YesNo
Can you work weekends?

YesNo
Can you work holidays?

YesNo
What date are you available to start work MMDDYYYY

MonthDayYear
Date
NOTES
WORK EXPERIENCE JOB 1
Name of Business/Employer: Employment Dates: Phone/Email
Name of BusinessEmployer
Start MMYY
End MMYY
Job TitlePosition
Person to Contact
Location
Position in Company
Reason for Leaving Company
Do you allow a representative from our company contact your most recent employer?
Do you allow a representative from our company contact your most recent employer?

YesNo
Name of Business/Employer: Employment Dates: Phone/Email
Name of BusinessEmployer
End MMYY
Job TitlePosition
Person to Contact
Location
Position in Company
Reason for Leaving Company
Name of Business/Employer: Employment Dates: Phone/Email
Name of BusinessEmployer
End MMYY
Job TitlePosition
Person to Contact
Location
Position in Company
Reason for Leaving Company
TRANSPORTATION
Do you currently hold a driver's license? What is your current mode of transportation? What is your driver's license number?
Would you be willing to provide a driving record?
Location where the licence was issued
Drivers License Number
What is your current mode of transportation
Licence Expiration Date MMDDYY

MonthDayYear
Date
How many
If yes please explain
Any driving accidents in the past three years? If yes, please explain?
How many
If yes please explain
COMMUNICATION
Additional Notes
Check the technology devices that you use: Do you have a data plan on your mobile device? Will you be willing to fill out a caregiver daily checklist after each visit? Additional Notes:

PERSONAL REFERENCE CONTACTS (Excluding family members) Reference 1
Name
Email
example@example.com
Connection
Phone
Have they been notified that they are a reference? Reference 2
YES NO
Name
Connection
Phone
Email
example@example.com
Have they been notified that they are a reference? Reference 2
YESINO
Name
Connection
Phone
Email
example@example.com
Have they been notified that they are a reference?
EDUCATION INFORMATION LEVEL OF EDUCATION
NAME OF SCHOOL
PROGRAM
COMPLETED
YESNO YESNO YESNO YES NO YES NO NO YES YESNO YESNO
RECOGNITION(S) OR ACCOMPLISHMENT(S) LIST BELOW
DATE [MM/DD/YY]
CRIMINAL BACKGROUND
Have you ever been charged with a criminal offence? If so, please explain:
If so please explain
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the employer permission to contact schools, previous employers (unless otherwise indicated), and references. This is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, or age. We assure you that your opportunity for this employment position depends solely on your qualifications.
Full Name of Applicant
DATE

MonthDayYear
Date
Thank you for completing this application form and for your interest in our company
Full name of authorized personnel
Signature of authorized personnel
Position title of authorized personnel
Date MMDDYYYY

MonthDayYear
Date
ADDITIONAL EMPLOYER NOTES
Should be Empty:

AVAILABILITY

WORK EXPERIENCE JOB 1

TRANSPORTATION

COMMUNICATION

YES NO

YESINO

EDUCATION INFORMATION LEVEL OF EDUCATION

NAME OF SCHOOL

PROGRAM

COMPLETED

RECOGNITION(S) OR ACCOMPLISHMENT(S) LIST BELOW

DATE [MM/DD/YY]

CRIMINAL BACKGROUND